<form method="get" action="/payment/do">
    <div class="well" style="width: 250px; padding: 10px 19px; margin: 20px auto;">
    <input type="text" name="money" value="10" /><br>
    <select name="mode">
        <option value="e">Express</option>
        <option value="d">Direct</option>
    </select><br>
    <input type="submit" value="Заказать" class="btn">
    </div>
</form>

